Piles of work to do 'later', infrequent decision making for groups of patients, batching work and lists all represent a wait in a patient journey or diagnostic pathway. These tend to occur when a particular type of work is done at one time. For example, a consultant who builds up all her reports on test results for the week, to do on one day.
To reduce unnecessary waits, you need to reduce piles of paperwork, ensure frequent decision making and reduce batching or batch sizes in diagnostics and waiting lists.
Grouping work to do 'later', either by time or by type, causes peaks and troughs in demand for the next step in the process - like mini rush hours in the system. This can be difficult for some parts of the healthcare system (eg diagnostics) where they have requests for work from many different sources.
"Artificially induced rush hours are endemic in the NHS: in day care where all patients are asked to arrive at 8am, even if some of them won’t be treated until noon; when samples are held back in pathology so they can be processed in batches; when a surgeon conducts many similar procedures one after the other thus flooding the wards with a sudden rush of patients needing similar treatment."
Dan Jones, 2006
Other examples of piles, batches and grouping include:
- A particular diagnostic test is only carried out once a week
- Letters are typed up once every three days
- Multi-disciplinary teams meet fortnightly
- Delays and time spent by a consultant to justify GP requests for ultrasound / other diagnostic tests (when 'wrong' referral rates are low)
Reducing unnecessary waiting along a patient journey and diagnostic pathways will have two impacts on 18 week waits by:
- Shortening referral to treatment time
- Reducing variation in different team's demand along the patient journey or pathway
1. Define: Understand if unnecessary delays and batching are a problem.
As a starting point, you will probably need to spend time on the following three activities:
- Identifying patterns of work that contribute to delays and where work is routinely piled up or batched together
- Gathering evidence
- Getting the understanding and mindset about how it contributes to delays
This work involves a strong human dimension, so it is important to understand different people's perspectives. See clinical engagement and staff perception. Sometimes evidence on its own isn't enough.
This can be illustrated by example: a consultant reverts back to her original behaviour of weekly decision making despite evidence that patients wait less if she reports on the same day as the CT exam. Why? Because it is easier for her to report in one big group in a dedicated time slot. Understanding the impact of change on individuals and developing systems to make the default easier is a critical way of thinking. Consider 'what is in it for me?' on behalf of your patients.
You may find that spending time watching how people work gives you ideas about which changes would work for them. For example, making sure that a surgeon is allocated extra time to make reports, or working out how to make the reports a quicker and easier process.
Next, identify the patterns of work and where unnecessary delays occur along patient or diagnostic pathways. Map out the process, ideally with your team:
Compare patterns of working and discuss with your team. Use these comparisons to understand the difference in journey times for different patients on the same pathway. This will highlight the scope of opportunities for improvement and generate discussion.
Which approach you use will depend upon your team and focus. It is better to include and involve people as early as possible so they can identify the solutions themselves.
2. Diagnose: Build up evidence of the impact of delays on patients.
Lots of small delays add up: big delays are more obvious.
- Identify a simple measure that you can collect easily to help you monitor progress. For example, the total pathway or process time using 'clock-in the time' and 'clock-out the time' (and date if necessary)
- You can plot these on graph paper or electronically. Your information department may be able to help you; they may also have some useful information already
- Look for something you can plot and show other members of the team. You are not trying to conduct a research study; a measure that is 'good enough' will do
3. Decide next steps: Identify options for improvement.
A lot of solutions will become obvious to people when they see the process maps and have an opportunity to discuss what is going on.
Make a change in the process:
- Reduce the number of steps in the patient pathway / diagnostic pathways: this reduces the opportunities for grouping, piling and batching work
People make changes in the way they work:
- Increase frequency of times when decisions are made / work is done
- Shift habits and patterns eg 'do today's work today'
Support the changes:
- Make sure there is time allocated for the change eg paperwork (it should be included in capacity and demand analysis)
- Look at changing behaviour and make it easier to batch less
System change:
- Schedule referrals or work as it comes in (the scheduling systems need to be in line with capacity and demand for the work)
A consultant groups and reviews her CT examination results once a week. This is because she believes her efficiency is important; by grouping them, she spends less time on each CT exam. This increases waiting. Her patients wait anywhere between one and nine days for their diagnostic assessment. However, when she tried reporting at the same time as the exam, waiting times were less than two and a half days.
Imagine you are this consultant's patient. You could wait up to nine days for a CT scan report just because she doesn't review and report on the day of your scan. This is only one stage in your journey which can easily take up seven percent of an 18 week pathway.
Start improvements at the end of the patient journey and the diagnostic pathway otherwise you may get a 'tidal' wave of demand for work. This is because, as all the mini waiting lists and piles of work are done, they move onto the next stage ie your backlog becomes someone else's 'to do' list.
If you know where the bottleneck is along the patient pathway or diagnostic pathway, you can use this to plan your improvements (see managing bottlenecks):
- Improvements before a bottleneck are likely to result in increased waiting just before the bottleneck
- Improvements at the bottleneck may result in increased throughput of patients along the pathway
- Improvements after the bottleneck are likely to result in decreased patient journey times but not increased number of patients seen along the pathway
You also need to take additional steps to increase the number of patients or tests that can be dealt with. This releases existing capacity or adds additional capacity (see quick introduction to capacity and demand).
Once you have decided on the steps you will undertake, you can utilise small tests of change (see plan do study act) to test and implement these steps.
Monitoring your changes is very important. Build up evidence of your improvement (see the improvement leaders' guide on measuring for improvement). This will enable you to use your simple measures to show how delays have been reduced and to observe if the change has been sustained.
The principles originate from Lean thinking (sometimes called the Toyota model) and a focus on improving flow. The idea is to 'keep things moving' as waiting is one of the seven wastes in systems. Having a steady, routine flow of work makes things predictable and manageable. Many peaks and troughs in work are caused by our way of working. (See variation: what it is)
A range of experts helped us to develop the six things: operational managers in NHS services and experts in Lean and Clinical Systems Improvement. We are grateful for their time, their insights and their knowledge.
Quote in body text is referenced from Lean thinking for the NHS.